Prevention, a touchstone of public health, has landed in the crosshairs of the national health reform debate, with cost-effectiveness pitted against the sometimes incalculable value of a healthy life.
Recent questions about prevention’s ability to save health care dollars have elicited a barrage of responses and critiques, many from public health advocates and researchers, who not only contend that the wrong questions are being asked, but that prevention is being held to an unfair standard. While prevention techniques have no doubt saved lives, fended off further disease and disability, and sparked countless people to change their behaviors, they have also been touted as a way to curb health care spending. In a speech before a joint session of Congress in September, President Barack Obama said his health reform plan will require insurance companies to cover preventive care such as mammograms and colonoscopies, "because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives." Some observers, however, argue that such economic claims are stretching the truth, pointing to research that such preventive care will increase medical spending instead.
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| Melvin Bennett is checked for glaucoma in June at a New York City health fair that offered free preventive screenings. The value of prevention has become part of the debate on health reform. Photo by Spencer Platt, courtesy Getty Images |
In an August Congressional Budget Office letter, office Director Douglas Elmendorf wrote that "although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall." On an individual level, a clinical preventive screening that catches a disease in its early stages can lower spending, the budget office reported, but because such screenings are applied over large populations — many of whom will not develop the particular disease being screened for — the tactic adds to, not reduces, medical spending.
The letter said that while clinical preventive services can increase a person’s lifespan, such an outcome "could add to federal spending in the long run," such as increased utilization of Social Security and Medicare benefits. The budget office, which is tasked with providing Congress with objective analyses to aid in budgetary decisions, also examined private and public wellness programs, such as workplace health promotions and the decades-long campaign to reduce smoking, but found the "effect of wellness services on subsequent spending on health care is limited."
The letter also noted that just because preventive care may add to spending does not mean it is a "bad investment," noting that "experts have concluded that a large fraction of prevention care adds to spending but should be deemed ‘cost-effective,’ meaning that it provides clinical benefits that justify those added costs." Many advocates of prevention agree with the last statement, but stress that the debate on prevention is much too narrow — that prevention happens inside and outside the doctor’s office and should be judged on more than the money it saves.
"If there was a mistake, in retrospect, it was talking about (prevention in terms of) cost-effectiveness, which not everybody understands," said Jonathan Fielding, MD, MPH, MBA, director of public health at the Los Angeles County Department of Public Health. "But people do understand that when they shop, what they want is value. How much health are we getting for the dollar invested?"
The Congressional Budget Office letter is not the only recent analysis to argue against prevention’s cost-effectiveness. Several other high-profile studies in journals such as the New England Journal of Medicine and Health Affairs examined clinic-based tactics such as cancer screenings or prescribing cholesterol medication to prevent coronary heart disease, calling into question the dollar value of such strategies.
With such questions coming to the forefront, the task ahead is to reframe the prevention debate, said Rob Gould, PhD, president of the Partnership for Prevention. Focusing on how much money prevention costs or saves the federal budget is the wrong question, Gould told The Nation’s Health. Instead, the discussion should focus on questions of value, he said, whether the money being spent is a good investment.
"We should not be apologizing for helping people live longer and healthier lives, especially when we can deliver that life at the right cost," said Gould, an APHA member. "The good news is that the public wants prevention in health care, even if it costs more, so we’re starting from a good place in terms of public support. But we have to answer the economic questions, and we need to talk about cost in terms of value."
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A poster reminding people to help prevent the spread of infectious disease by covering their coughs is displayed in a New York City office building in September. The value of such health promotion measures can be difficult to account for when assessing prevention’s cost-effectiveness. Photo by Mario Tama, courtesy Getty Images |
In September, the Partnership for Prevention released and sent to policy-makers a report on the "Economic Argument for Disease Prevention: Distinguishing Between Value and Savings," which stated that "health is a good, and goods — whether they are national security, clean water or a new car — are not purchased to save money. They are purchased for the nonmonetary benefits they provide. Shoppers do not buy groceries to save money, but they do ‘save money’ by shopping wisely." The report noted that prevention can result in other benefits that usually go unmeasured in studies on cost-effectiveness, such as improving "work force productivity and corporate competitiveness," as well as the ripple effects good health can bring to households and children, educational attainment and crime rates. A similar report released in August by the Robert Wood Johnson Foundation, "Cost-Savings and Cost-Effectiveness of Clinical Preventive Care," found that even while clinic-based preventive care, such as cancer screenings, do not usually result in cost savings, such services "offer good value for increasingly scarce health care dollars."
"The question really isn’t about whether prevention saves money — that’s a false standard," said Steven Teutsch, MD, MPH, chief science officer at the Los Angeles County Department of Public Health, during the Sept. 22 news conference releasing the Robert Wood Johnson Foundation report. "Few things in life actually save money and we need to hold prevention to that same standard: What is the value you’re getting for what you’re purchasing?"
Ken Thorpe, PhD, MA, a professor of health policy at Emory University and co-director of the university’s Institute for Health and Productivity Studies, noted that the budget office report only examined one of the three major prevention categories: clinic-based prevention such as screenings and immunizations, and not population-based prevention techniques designed to prevent disease in the first place or prevention aimed at deterring complications in people already chronically ill. It is the two latter techniques that are really designed, in part, to reduce costs, whereas the prevention strategy that the budget office focused on "wasn’t designed to save money but to give people a chance at a better quality of life," Thorpe told The Nation’s Health.
"What’s frustrating about this process is that there’s not a good discussion about other forms of prevention, about designing effective interventions," said Thorpe, an APHA member. "These are the types of health reform discussions we should be having."
During a Sept. 21 news conference hosted by Trust for America’s Health, researchers released a "Compendium of Proven Community-Based Prevention Programs," finding that population-based prevention does offer a high return on investment. For example, the Pawtucket Heart Health Program in Rhode Island implemented an intervention to educate 71,000 residents about heart disease via mass media and community outreach. Five years into the effort, risk for cardiovascular and coronary heart disease had decreased by 16 percent among the intervention group, the compendium reported.
"Despite the high rates of preventable death, investment in prevention has been historically modest in this country, accounting for only 4 percent of all health expenditures," said Jo Ivey Bufford, MD, president of the New York Academy of Medicine, which compiled the compendium. "The good news is that community-based prevention programs work. Well-designed community interventions can change behavior."
While access to high quality health care is critical, health reform must include incentives that help communities pull together and create the conditions that help people make healthy choices and ultimately lead to reduced demands on the medical system, Bufford said during the news conference. Jeff Levi, PhD, executive director of Trust for America’s Health, said that both Congress and the Obama administration recognize the potential for community-based prevention programs, pointing to the "unprecedented level" of potential investment in prevention included in the health reform bills now being proposed, adding that "it’s a tremendous opportunity to change the balance."
"We all use the word ‘prevention’ in a different way and, unfortunately, we haven’t begun to unravel that communication problem," said Levi, an APHA member. "In the world of some actuaries, if you live longer, you cost more and that therefore is a bad thing. We would hope policy-makers are not thinking in those terms. Health reform cannot and should not just be about rearranging numbers on a spreadsheet."
Fielding of Los Angeles, who is also co-author of the Partnership for Prevention report, stressed that "what’s missing from the (prevention) debate is that the key metric is value."
"There are prevention activities that will save money, but most prevention activities are simply a good investment," said Fielding, an APHA member. "We may not save in terms of health care costs, but it’s a good value compared to the spending we do now on medical care, in treatment and on the diagnostic side."
For more information on the value of prevention, visit www.prevent.org, www.tfah.org or www.rwjf.org.